Epinephrine and dexamethasone in children with bronchiolitis

Respiratory Syncytial Virus: The Urgent Need for Innovative Preventive Strategies

Respiratory Syncytial Virus (RSV) is a medium-sized enveloped Pneumovirus belonging to the Paramyxoviridae family [...].

Bronchiolitis: Safely Doing Less Is the Next Big Thing

Bronchiolitis is a viral lower respiratory tract infection primarily affecting children younger than 2 years; a common cause of health care encounters, including hospitalization; and a considerable economic burden for health care systems in the United States and worldwide. The American Academy of Pediatrics (AAP) most recently updated its bronchiolitis guideline in 2014 and reaffirmed supportive care as the mainstay of treatment. Despite these recommendations, there is still significant variability in care provided for these children, especially in bronchodilator usage, radiography, and high-flow nasal cannula. Since the 2014 AAP guideline, many pediatric hospitalists have undertaken quality initiatives to improve the adherence to published guidelines, yet a large gap remains between what is recommended and what is practiced. This article presents research on the efficacy of common interventions as well as an introduction to diagnostics and treatments potentially on the horizon. [Pediatr Ann. 2024;53(6):e223-e228.].

Expert consensus on the diagnosis, treatment, and prevention of respiratory syncytial virus infections in children

BACKGROUND

Respiratory syncytial virus (RSV) is the leading global cause of respiratory infections and is responsible for about 3 million hospitalizations and more than 100,000 deaths annually in children younger than 5 years, representing a major global healthcare burden. There is a great unmet need for new agents and universal strategies to prevent RSV infections in early life. A multidisciplinary consensus development group comprising experts in epidemiology, infectious diseases, respiratory medicine, and methodology aims to develop the current consensus to address clinical issues of RSV infections in children.

DATA SOURCES

The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, using variations in terms for "respiratory syncytial virus", "RSV", "lower respiratory tract infection", "bronchiolitis", "acute", "viral pneumonia", "neonatal", "infant" "children", and "pediatric".

RESULTS

Evidence-based recommendations regarding diagnosis, treatment, and prevention were proposed with a high degree of consensus. Although supportive care remains the cornerstone for the management of RSV infections, new monoclonal antibodies, vaccines, drug therapies, and viral surveillance techniques are being rolled out.

CONCLUSIONS

This consensus, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of RSV infections. Further improvements in the management of RSV infections will require generating the highest quality of evidence through rigorously designed studies that possess little bias and sufficient capacity to identify clinically meaningful end points.

Admissions for Bronchiolitis at Children's Hospitals Before and During the COVID-19 Pandemic

Importance

The COVID-19 pandemic has been associated with a transient decrease in bronchiolitis hospitalizations compared with prepandemic patterns, but current effects remain unknown.

Objective

To analyze changes in patterns of bronchiolitis admissions at US children's hospitals during the 2020-2023 bronchiolitis seasons compared with the 2010-2019 seasons.

Design, Setting, and Participants

This retrospective cross-sectional study used data from 41 US children's hospitals in the Pediatric Health Information System database. Bronchiolitis has winter-predominant seasonality, so hospitalizations were grouped according to bronchiolitis season (from July through June). This study included all patients aged younger than 2 years admitted with a diagnosis of bronchiolitis between July 1, 2010, and June 30, 2023. Bronchiolitis seasons from July through June between 2010-2011 and 2019-2020 were classified as the prepandemic era, and seasons between 2020-2021 and 2022-2023 were classified as the pandemic era. Data analysis was performed from July 1, 2010, through June 30, 2023.

Exposures

Admission date.

Main Outcomes and Measures

The primary outcome was number of hospitalizations for bronchiolitis by season and month. Monthly admission counts from the prepandemic era were transformed into time series and used to train seasonal ensemble forecasting models. Forecasts were compared to monthly admissions during the pandemic era.

Results

In this study, there were 400 801 bronchiolitis admissions among 349 609 patients between July 1, 2010, and June 30, 2023. The median patient age was 6 (IQR, 2-12) months; 58.7% were boys and 43.7% were White. Hospitalizations increased gradually during the prepandemic era (median, 29 309 [IQR, 26 196-34 157]), decreased 69.2% (n = 9030) in the 2020-2021 season, and increased 75.3% (n = 51 397) in the 2022-2023 season. Patients in the pandemic era were older than those in the prepandemic era (median, 7 [IQR, 3-14] vs 6 [2-12] months; P < .001). Intensive care unit (ICU) admissions increased from 32.2% (96 245 of 298 535) in the prepandemic era to 36.7% (37 516 of 102 266) in the pandemic era (P < .001). The seasonality of bronchiolitis admissions changed during the pandemic era. Admissions peaked in August 2021 (actual 5036 vs 943 [95% CI, 0-2491] forecasted) and November 2022 (actual 10 120 vs 5268 [95% CI, 3425-7419] forecasted). These findings were unchanged in sensitivity analyses excluding children with complex chronic conditions and excluding repeat admissions. In a sensitivity analysis including all viral lower respiratory tract infections in children aged younger than 5 years, there were 66 767 admissions in 2022-2023 vs 35 623 (31 301-41 002) in the prepandemic era, with the largest increase in children aged 24 to 59 months.

Conclusions and Relevance

The findings of this cross-sectional study suggest that bronchiolitis hospitalizations decreased transiently and then increased markedly during the COVID-19 pandemic era. Patients admitted during the pandemic era were older and were more likely to be admitted to an ICU. These findings suggest that bronchiolitis seasonality has not yet returned to prepandemic patterns, and US hospitals should prepare for the possibility of atypical timing again in 2023.

Controlling viral inflammatory lesions by rebalancing immune response patterns

In this review, we discuss a variety of immune modulating approaches that could be used to counteract tissue-damaging viral immunoinflammatory lesions which typify many chronic viral infections. We make the point that in several viral infections the lesions can be largely the result of one or more aspects of the host response mediating the cell and tissue damage rather than the virus itself being directly responsible. However, within the reactive inflammatory lesions along with the pro-inflammatory participants there are also other aspects of the host response that may be acting to constrain the activity of the damaging components and are contributing to resolution. This scenario should provide the prospect of rebalancing the contributions of different host responses and hence diminish or even fully control the virus-induced lesions. We identify several aspects of the host reactions that influence the pattern of immune responsiveness and describe approaches that have been used successfully, mainly in model systems, to modulate the activity of damaging participants and which has led to lesion control. We emphasize examples where such therapies are, or could be, translated for practical use in the clinic to control inflammatory lesions caused by viral infections.

Intensivists' Reported Management of Critical Bronchiolitis: More Data and New Guidelines Needed

OBJECTIVES

Existing bronchiolitis guidelines do not reflect the needs of infants admitted to the PICU. This study aimed to identify PICU providers' reported practice variations and explore the need for critical bronchiolitis clinical guidelines.

METHODS

Cross-sectional electronic survey available in English, Spanish, and Portuguese between November 2020 and March 2021, distributed via research networks from North and Latin America, Asia, and Australia/New Zealand.

RESULTS

A total of 657 PICU providers responded, including 344 English, 204 Spanish, and 109 Portuguese. PICU providers indicated frequently using (≥25% of time) diagnostic modalities for nonintubated and intubated patients on PICU admission (complete blood count [75%-97%], basic metabolic panel [64%-92%], respiratory viral panel [90%-95%], chest x-ray [83%-98%]). Respondents also reported regularly (≥25% of time) prescribing β-2 agonists (43%-50%), systemic corticosteroids (23%-33%), antibiotics (24%-41%), and diuretics (13%-41%). Although work of breathing was the most common variable affecting providers' decision to initiate enteral feeds for nonintubated infants, hemodynamic status was the most common variable for intubated infants (82% of providers). Most respondents agreed it would be beneficial to have specific guidelines for infants with critical bronchiolitis who are requiring both noninvasive (91% agreement) and invasive (89% agreement) respiratory support.

CONCLUSIONS

PICU providers report performing diagnostic and therapeutic interventions for infants with bronchiolitis more frequently than recommended by current clinical guidelines, with interventions occurring more frequently for infants requiring invasive support. More clinical research is needed to inform the creation of evidence-based guidelines specifically for infants with critical bronchiolitis.

Hyperhydration to Improve Kidney Outcomes in Children with Shiga Toxin-Producing E. coli Infection: a multinational embedded cluster crossover randomized trial (the HIKO STEC trial)

BACKGROUND

Shiga toxin-producing E. coli (STEC) infections affect children and adults worldwide, and treatment remain solely supportive. Up to 15-20% of children infected by high-risk STEC (i.e., E. coli that produce Shiga toxin 2) develop hemolytic anemia, thrombocytopenia, and kidney failure (i.e., hemolytic uremic syndrome (HUS)), over half of whom require acute dialysis and 3% die. Although no therapy is widely accepted as being able to prevent the development of HUS and its complications, several observational studies suggest that intravascular volume expansion (hyperhydration) may prevent end organ damage. A randomized trial is needed to confirm or refute this hypothesis.

METHODS

We will conduct a pragmatic, embedded, cluster-randomized, crossover trial in 26 pediatric institutions to determine if hyperhydration, compared to conservative fluid management, improves outcomes in 1040 children with high-risk STEC infections. The primary outcome is major adverse kidney events within 30 days (MAKE30), a composite measure that includes death, initiation of new renal replacement therapy, or persistent kidney dysfunction. Secondary outcomes include life-threatening, extrarenal complications, and development of HUS. Pathway eligible children will be treated per institutional allocation to each pathway. In the hyperhydration pathway, all eligible children are hospitalized and administered 200% maintenance balanced crystalloid fluids up to targets of 10% weight gain and 20% reduction in hematocrit. Sites in the conservative fluid management pathway manage children as in- or outpatients, based on clinician preference, with the pathway focused on close laboratory monitoring, and maintenance of euvolemia. Based on historical data, we estimate that 10% of children in our conservative fluid management pathway will experience the primary outcome. With 26 clusters enrolling a mean of 40 patients each with an intraclass correlation coefficient of 0.11, we will have 90% power to detect a 5% absolute risk reduction.

DISCUSSION

HUS is a devastating illness with no treatment options. This pragmatic study will determine if hyperhydration can reduce morbidity associated with HUS in children with high-risk STEC infection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05219110 . Registered on February 1, 2022.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Clinical application of a lung sound analysis in infants with respiratory syncytial virus acute bronchiolitis

BACKGROUND

Objective investigation of the characteristics of acute bronchiolitis in infants is important for its diagnosis and treatment.

METHODS

Lung sound data of 50 patients diagnosed with respiratory syncytial virus (RSV) acute bronchiolitis (m:f = 29:21, median of age 7 months), 20 patients with RSV acute respiratory tract infections without acute bronchiolitis (m:f = 10:10, 5 months) and 38 age-matched control infants (m:f = 23:15, 8 months) were analyzed using a conventional method and compared. Furthermore, the relationships between lung sound parameters and clinical symptoms (clinical score, length of hospital stay and SpO2 level) in the bronchiolitis and the non-bronchiolitis patients were examined.

RESULTS

Results of lung sound analysis showed that the inspiratory sound power of patients with RSV respiratory tract infections was low and the expiratory sound power was high compared with those of the controls. When the patients with RSV respiratory tract infections were divided into the bronchiolitis and non-bronchiolitis groups, the expiratory/inspiratory ratio of the bronchiolitis patients was greater than that of the non-bronchiolitis patients. There was no difference in the clinical symptoms, clinical score and length of hospital stay between the bronchiolitis and non-bronchiolitis patients, except for the SpO2 level on admission.

CONCLUSION

Lung sound analysis confirmed that patients with RSV acute bronchiolitis present with marked airway narrowing. Considering these results as a characteristic of acute bronchiolitis, it would be meaningful to reflect it in the improvement of diagnosis, treatment and subsequent management.

Respiratory virus type to guide predictive enrichment approaches in the management of the first episode of bronchiolitis: A systematic review

It has become clear that severe bronchiolitis is a heterogeneous disease; even so, current bronchiolitis management guidelines rely on the one-size-fits-all approach regarding achieving both short-term and chronic outcomes. It has been speculated that the use of molecular markers could guide more effective pharmacological management and achieve the prevention of chronic respiratory sequelae. Existing data suggest that asthma-like treatment (systemic corticosteroids and beta2-agonists) in infants with rhinovirus-induced bronchiolitis is associated with improved short-term and chronic outcomes, but robust data is still lacking. We performed a systematic search of PubMed, Embase, Web of Science, and the Cochrane’s Library to identify eligible randomized controlled trials to determine the efficacy of a personalized, virus-dependent application of systemic corticosteroids in children with severe bronchiolitis. Twelve studies with heterogeneous methodology were included. The analysis of the available results comparing the respiratory syncytial virus (RSV)-positive and RSV-negative children did not reveal significant differences in the associatons between systemic corticosteroid use in acute episode and duration of hospitalization (short-term outcome). However, this systematic review identified a trend of the positive association between the use of systematic corticosteroids and duration of hospitalization in RSV-negative infants hospitalized with the first episode of bronchiolitis (two studies). This evidence is not conclusive. Taken together, we suggest the design for future studies to assess the respiratory virus type in guiding predictive enrichment approaches in infants presenting with the first episode of bronchiolitis.

Breath sound analyses of infants with respiratory syncytial virus acute bronchiolitis

INTRODUCTION

The reliability of a breath sound analysis using an objective method in infants has been reported.

OBJECTIVE

Breath sounds of infants with respiratory syncytial virus (RSV) acute bronchiolitis were analyzed via a breath sound spectrogram to evaluate their characteristics and examine their relationship with the severity.

SUBJECTS AND METHODS

We evaluated the inspiratory and expiratory breath sound parameters of 33 infants diagnosed with RSV acute bronchiolitis. The sound powers of inspiration and expiration were evaluated at the acute phase and recovery phase of infection. Furthermore, the relationship between the breath sound parameters and the clinical severity of acute bronchiolitis was examined.

RESULTS

Analyses of the breath sound spectrogram showed that the power of expiration as well as the expiration-to-inspiration sound ratio in the mid-frequency (E/I MF) was increased in the acute phase and decreased during the recovery phase. The E/I MF was inversely correlated with the SpO₂ and positively correlated with the severity score.

CONCLUSION

In infants with RSV acute bronchiolitis, the sound power of respiration was large at the acute phase, significantly decreasing in the recovery phase. In 61% of participants, nonuniform, granular bands were shown in the low-pitched region of the expiratory spectrogram.

Bronchiolitis

Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.

Pragmatic Randomized Trial of Corticosteroids and Inhaled Epinephrine for Bronchiolitis in Children in Intensive Care

OBJECTIVE

To determine whether the combination of systemic corticosteroids and nebulized epinephrine, compared with standard care, reduces the duration of positive pressure support in children with bronchiolitis admitted to intensive care.

STUDY DESIGN

We performed a pragmatic, multicenter, open-label, randomized trial between July 2013 and November 2019 in children younger than 18 months old with a clinical diagnosis of bronchiolitis. The intervention group received the equivalent of 13 mg/kg prednisolone over 3 days, then 1 mg/kg daily for 3 days, plus 0.05 mL/kg of nebulized 1% epinephrine made up to 6 ml with 0.9% saline via jet nebulizer and mask using oxygen at 12 l/min every 30 minutes for 5 doses, then 1-4 hourly for 3 days, then as required for 3 days. The primary outcome was clinician-managed duration of positive pressure support in intensive care defined as high-flow nasal-prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation.

RESULTS

In total, 210 children received positive pressure support. In the corticosteroid-epinephrine group, 107 children received positive pressure support for a geometric mean of 26 (95% CI, 22-32) hours compared with 40 (95% CI 34-47) hours in 103 controls, adjusted ratio 0.66 (95% CI 0.51-0.84), P = .001. In the intervention group, 41 (38%) children experienced at least 1 adverse event, compared with 39 (38%) in the control group.

CONCLUSIONS

In children with severe bronchiolitis, the duration of clinician-managed pressure support was reduced by regular treatment with systemic corticosteroids and inhaled epinephrine compared with standard care.

CLINICAL TRIAL REGISTRATION

Australian Clinical Trials Research Network: ACTRN12613000316707.

Remote, real-time expert elicitation to determine the prior probability distribution for Bayesian sample size determination in international randomised controlled trials: Bronchiolitis in Infants Placebo Versus Epinephrine and Dexamethasone (BIPED) study

Background

Bayesian methods are increasing in popularity in clinical research. The design of Bayesian clinical trials requires a prior distribution, which can be elicited from experts. In diseases with international differences in management, the elicitation exercise should recruit internationally, making a face-to-face elicitation session expensive and more logistically challenging. Thus, we used a remote, real-time elicitation exercise to construct prior distributions. These elicited distributions were then used to determine the sample size of the Bronchiolitis in Infants with Placebo Versus Epinephrine and Dexamethasone (BIPED) study, an international randomised controlled trial in the Pediatric Emergency Research Network (PERN). The BIPED study aims to determine whether the combination of epinephrine and dexamethasone, compared to placebo, is effective in reducing hospital admission for infants presenting with bronchiolitis to the emergency department.

Methods

We developed a Web-based tool to support the elicitation of the probability of hospitalisation for infants with bronchiolitis. Experts participated in online workshops to specify their individual prior distributions, which were aggregated using the equal-weighted linear pooling method. Experts were then invited to provide their comments on the aggregated distribution. The average length criterion determined the BIPED sample size.

Results

Fifteen paediatric emergency medicine clinicians from Canada, the USA, Australia and New Zealand participated in three workshops to provide their elicited prior distributions. The mean elicited probability of admission for infants with bronchiolitis was slightly lower for those receiving epinephrine and dexamethasone compared to supportive care in the aggregate distribution. There were substantial differences in the individual beliefs but limited differences between North America and Australasia. From this aggregate distribution, a sample size of 410 patients per arm results in an average 95% credible interval length of less than 9% and a relative predictive power of 90%.

Conclusion

Remote, real-time expert elicitation is a feasible, useful and practical tool to determine a prior distribution for international randomised controlled trials. Bayesian methods can then determine the trial sample size using these elicited prior distributions. The ease and low cost of remote expert elicitation mean that this approach is suitable for future international randomised controlled trials.

Trial registration

ClinicalTrials.govNCT03567473

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06240-w.

Treatment of the most common respiratory infections in children

Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.

Management of Wheezy Preschoolers in the Emergency Department: A Discrete Choice Experiment

OBJECTIVES

This study aimed to elicit pediatric emergency physician's treatment choices for preschool-aged children with wheeze, determine the characteristics of the presenting child that influence treatment choices, and determine whether there is clinical equipoise by eliciting physician willingness to enroll these children in a placebo-controlled trial of corticosteroids.

METHODS

Discrete choice experiments varying the characteristics of the presenting child were designed to elicit Canadian emergency physician's treatment choices, both in the emergency department (ED) and at discharge, for young children presenting with wheeze and their willingness to enroll in a randomized controlled trial (RCT).

RESULTS

Most physicians chose to treat children with albuterol both in the ED and at discharge for all clinical scenarios. The proportion of physicians who chose to treat children with oral corticosteroids both in the ED and at discharge varied widely (from 12% to 81%) across all scenarios. Physician preference whether preschool children with wheeze should be treated with corticosteroids varied depending on the child's age, history of atopy, and previous and continuous wheeze. Between 73% and 86% of physicians were willing to enroll these children in an RCT indicating clinical equipoise.

CONCLUSIONS

Physician treatment choices varied widely indicating clinical equipoise as to the effectiveness of corticosteroids in this population of patients. Management choices with respect to albuterol and corticosteroids were not consistent with published national and international guidelines. In line with this finding, physician's considerable willingness to enroll these children in an RCT may suggest that they are seeking guidance on how to manage these patients.

Occurrence, Fate, Effects, and Risks of Dexamethasone: Ecological Implications Post-COVID-19

The recent outbreak of respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease (COVID-19), has led to the widespread use of therapeutics, including dexamethasone (DEXA). DEXA, a synthetic glucocorticoid, is among the widely administered drugs used to treat hospitalized COVID-19 patients. The global COVID-19 surge in infections, consequent increasing hospitalizations, and other DEXA applications have raised concerns on eminent adverse ecological implications to aquatic ecosystems. Here, we aim to summarize published studies on DEXA occurrence, fate, and effects on organisms in natural and engineered systems as, pre-COVID, the drug has been identified as an emerging environmental contaminant. The results demonstrated a significant reduction of DEXA in wastewater treatment plants, with a small portion, including its transformation products (TPs), being released into downstream waters. Fish and crustaceans are the most susceptible species to DEXA exposure in the parts-per-billion range, suggesting potential deleterious ecological effects. However, there are data deficits on the implications of DEXA to marine and estuarine systems and wildlife. To improve DEXA management, toxicological outcomes of DEXA and formed TPs should entail long-term studies from whole organisms to molecular effects in actual environmental matrices and at realistic exposure concentrations. This can aid in striking a fine balance of saving human lives and protecting ecological integrity.

Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit

OBJECTIVE

To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide.

DESIGN

A descriptive and observational study was carried out between September 2010 and September 2017.

SETTING

Pediatric intensive care unit.

PATIENTS

Infants under one year of age with severe bronchiolitis.

INTERVENTIONS

Two periods were compared (2010-14 and 2015-17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital.

MAIN VARIABLES

Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality.

RESULTS

A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25-100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7-11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010-14) included 340 patients and the second period (2015-17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (P=.003).

CONCLUSIONS

Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.

Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit

OBJECTIVE

To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide.

DESIGN

A descriptive and observational study was carried out between September 2010 and September 2017.

SETTING

Pediatric intensive care unit.

PATIENTS

Infants under one year of age with severe bronchiolitis.

INTERVENTIONS

Two periods were compared (2010-14 and 2015-17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital.

MAIN VARIABLES

Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality.

RESULTS

A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25-100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7-11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010-14) included 340 patients and the second period (2015-17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (p=0.003).

CONCLUSIONS

Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.

Efficacy of inhaled salbutamol with and without prednisolone for first acute rhinovirus-induced wheezing episode

BACKGROUND

Acute rhinovirus-induced wheezing is common in young children and may respond to systemic corticosteroid. There are no trials on the efficacy of inhaled beta₂ -agonist in this clinical scenario.

OBJECTIVE

To study post hoc the short-term (up to 2 months) efficacy of inhaled beta₂ -agonist with and without oral corticosteroid in the first acute rhinovirus-induced severe wheezing episode in young hospitalized children.

METHODS

The study population came from two randomized controlled trials comparing oral prednisolone (2 mg/kg/d for 3 days) to placebo: Vinku (n = 35, NCT00494624) used high-dose regular nebulized salbutamol (0.15 mg/kg 2-4 h intervals) and Vinku2 (n = 60, NCT00731575, EudraCT 2006-007100-42) used inhaled salbutamol on-demand. Both studies used identical detailed follow-up assessments. The primary outcome of the former was the duration of hospitalization and of the latter the occurrence of and the time to a new physician-confirmed wheezing episode within 2 months after discharge. Treatment groups included salbutamol high-dose vs. salbutamol on-demand while adjusting for prednisolone status and acknowledging for interactions with exception of the duration of hospitalization in which prednisolone groups could not be fully used due to protocol differences.

RESULTS

Median age of subjects was 13 months, 32% were sensitized and 22% had doctor-diagnosed eczema. In the duration of hospitalization, salbutamol high-dose/placebo versus salbutamol on-demand/placebo groups did not differ (p = .12). In the occurrence of and time to relapse within 2 months, a significant group × treatment interaction was observed (both p = .02), such that high-dose group had less and longer time to relapses than on-demand group in prednisolone arm (both p < .05), but no difference was detected in placebo arm (both p > .26).

CONCLUSIONS

In young, hospitalized children with first episode of rhinovirus-induced wheezing, high-dose inhaled salbutamol may interact with oral prednisolone. However, further trials are warranted.

Risk of asthma in children diagnosed with bronchiolitis during infancy: protocol of a longitudinal cohort study linking emergency department-based clinical data to provincial health administrative databases

INTRODUCTION

The Canadian Bronchiolitis Epinephrine Steroid Trial (CanBEST) and the Bronchiolitis Severity Cohort (BSC) study enrolled infants with bronchiolitis during the first year of life. The CanBEST trial suggested that treatment of infants with a combined therapy of high-dose corticosteroids and nebulised epinephrine reduced the risk of admission to hospital. Our study aims to-(1) quantify the risk of developing asthma by age 5 and 10 years in children treated with high-dose corticosteroid and epinephrine for bronchiolitis during infancy, (2) identify risk factors associated with development of asthma in children with bronchiolitis during infancy, (3) develop asthma prediction models for children diagnosed with bronchiolitis during infancy.

METHODS AND ANALYSIS

We propose a longitudinal cohort study in which we will link data from the CanBEST and BSC study with routinely collected data from provincial health administrative databases. Our outcome is asthma incidence measured using a validated health administrative data algorithm. Primary exposure will be treatment with a combined therapy of high-dose corticosteroids and nebulised epinephrine for bronchiolitis. Covariates will include type of viral pathogen, disease severity, medication use, maternal, prenatal, postnatal and demographic factors and variables related to health service utilisation for acute lower respiratory tract infection. The risk associated with development of asthma in children treated with high-dose corticosteroid and epinephrine for bronchiolitis will be assessed using multivariable Cox proportional hazards regression models. Prediction models will be developed using multivariable logistic regression analysis and internally validated using a bootstrap approach.

ETHICS AND DISSEMINATION

Our study has been approved by the ethics board of all four participating sites of the CanBEST and BSC study. Finding of the study will be disseminated to the academic community and relevant stakeholders through conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN56745572; Post-results.

Predictive factors of continuous negative extrathoracic pressure management failure in children with moderate to severe respiratory syncytial virus infection

Continuous negative extrathoracic pressure (CNEP) might be beneficial for children with severe respiratory tract infections. However, there are no available data on the predictors of its failure among individuals with respiratory syncytial virus (RSV) infections. Here, we conducted a retrospective cohort study between October 1, 2015 and October 31, 2018 in hospitalized children with moderate to severe symptoms of respiratory syncytial virus (RSV) infections. We divided 45 children requiring CNEP ventilation with a non-fluctuating negative pressure of - 12 cm H2O into two groups. They were classified based on improvement or deterioration of their respiratory disorder under CNEP ventilation (responder group: n = 27, failure group: n = 18). Based on the univariate analysis, the responder and failure groups significantly differed in terms of median age, days elapsed from RSV onset to the initiation of CNEP, white blood cell count (WBC), titer of venous pCO2, body temperature at admission, and modified Wood-Downes Score (mWDS) 6 h after initiating CNEP. Based on a logistic regression analysis adjusted for age < 1 year upon admission, less than 5 days elapsed from RSV onset to the initiation of CNEP, not high value of WBC and body temperature at admission, and high values of mWDS 6 h after initiating CNEP were found to be significant independent risk factors for CNEP ventilation failure. The former two variables were associated with less failure (odds ratio was approximately 5), and the latter two variables are associated with more failure (odds ratio was approximately 8-9). Thus, CNEP could be a valid option for children with moderate to severe RSV infections, especially in those who were aged > 1 year, and specific clinical and laboratory findings.

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.

Anti-Asthmatic Effects of Saffron Extract and Salbutamol in an Ovalbumin-Induced Airway Model of Allergic Asthma

Introduction: Asthma is a chronic inflammatory disorder of the airways often characterized by airway remodeling and influx of inflammatory cells into the airways. Saffron (C. sativus) has been reported to possess anti-inflammatory, anti-allergic and immunomodulatory properties. Salbutamol is known to relax airway smooth muscles. Objective: To investigate the combined anti-asthmatic effect of C. sativus extract (CSE) and salbutamol in an ovalbumin (OVA)-induced asthma in rats. Materials and methods: Airway hyperresponsiveness (AHR) was induced in male Sprague-Dawley rats by OVA challenge and treated with CSE (30 mg/kg and 60 mg/kg i.p.) and salbutamol (0.5 mg/kg p.o) for 28 days. After the induction period, various hematological, biochemical, molecular (ELISA) and histological analyses were performed. Results: OVA-induced alterations observed in hematological parameters (total and differential cell counts observed in Bronchoalveolar Lavage Fluid (BALF) were significantly attenuated (p < 0.01) by CSE (30 mg/kg and 60 mg/kg) and salbutamol (0.5 mg/kg). The treatment combination also significantly decreased (p < 0.01) the levels of total protein and albumin in serum, BALF and lung tissues. Treatment with CSE and salbutamol significantly attenuated (p < 0.01) increase in OVA induced Th2 cytokine levels (TNF-α, IL-1β, IL-4, IL-13). Histopathological analysis of lung tissue showed that combined effect of CSE and salbutamol treatment ameliorated OVA-induced inflammatory influx and ultrastructural aberrations. Conclusion: The results obtained from this study show that the combined effect of CSE and salbutamol exhibited anti-asthmatic properties via its anti-inflammatory effect and by alleviating Th2 mediated immune response. Thus, this treatment combination could be considered as a new therapeutic strategy for management of asthma.

Prospective cohort study of children with suspected SARS-CoV-2 infection presenting to paediatric emergency departments: a Paediatric Emergency Research Networks (PERN) Study Protocol

INTRODUCTION

Relatively limited data are available regarding paediatric COVID-19. Although most children appear to have mild or asymptomatic infections, infants and those with comorbidities are at increased risk of experiencing more severe illness and requiring hospitalisation due to COVID-19. The recent but uncommon association of SARS-CoV-2 infection with development of a multisystem inflammatory syndrome has heightened the importance of understanding paediatric SARS-CoV-2 infection.

METHODS AND ANALYSIS

The Paediatric Emergency Research Network-COVID-19 cohort study is a rapid, global, prospective cohort study enrolling 12 500 children who are tested for acute SARS-CoV-2 infection. 47 emergency departments across 12 countries on four continents will participate. At enrolment, regardless of SARS-CoV-2 test results, all children will have the same information collected, including clinical, epidemiological, laboratory, imaging and outcome data. Interventions and outcome data will be collected for hospitalised children. For all children, follow-up at 14 and 90 days will collect information on further medical care received, and long-term sequelae, respectively. Statistical models will be designed to identify risk factors for infection and severe outcomes.

ETHICS AND DISSEMINATION

Sites will seek ethical approval locally, and informed consent will be obtained. There is no direct risk or benefit of study participation. Weekly interim analysis will allow for real-time data sharing with regional, national, and international policy makers. Harmonisation and sharing of investigation materials with WHO, will contribute to synergising global efforts for the clinical characterisation of paediatric COVID-19. Our findings will enable the implementation of countermeasures to reduce viral transmission and severe COVID-19 outcomes in children.

TRIAL REGISTRATION NUMBER

NCT04330261.

Day of Illness and Outcomes in Bronchiolitis Hospitalizations

BACKGROUND

Bronchiolitis is often described to follow an expected clinical trajectory, with a peak in severity between days 3 and 5. This predicted trajectory may influence anticipatory guidance and clinical decision-making. We aimed to determine the association between day of illness at admission and outcomes, including hospital length of stay, receipt of positive-pressure ventilation, and total cough duration.

METHODS

We compiled data from 2 multicenter prospective studies involving bronchiolitis hospitalizations in patients <2 years. Patients were excluded for complex conditions. We assessed total cough duration via weekly postdischarge phone calls. We used mixed-effects multivariable regression models to test associations between day of illness and outcomes, with adjustment for age, sex, insurance (government versus nongovernment), race, and ethnicity.

RESULTS

The median (interquartile range) day of illness at admission for 746 patients was 4 (2-5) days. Day of illness at admission was not associated with length of stay (coefficient 0.01 days, 95% confidence interval [CI]: -0.05 to 0.08 days), positive-pressure ventilation (adjusted odds ratio: 1.0, 95% CI: 0.9 to 1.1), or total cough duration (coefficient 0.33 days, 95% CI: -0.01 to 0.67 days). Additionally, there was no significant difference in day of illness at discharge in readmitted versus nonreadmitted patients (5.9 vs 6.4 days, P = .54). The median cough duration postdischarge was 6 days, with 65 (14.3%) patients experiencing cough for 14+ days.

CONCLUSIONS

We found no associations between day of illness at admission and outcomes in bronchiolitis hospitalizations. Practitioners should exercise caution when making clinical decisions or providing anticipatory guidance based on symptom duration.

Acute Viral Bronchiolitis: A Narrative Review

Acute viral bronchiolitis (AVB) is the leading cause of hospital admissions among infants in developed and developing countries and associated with increased morbidity and cost of treatment. This review was performed to guide the clinicians managing AVB in light of evidence accumulated in the last decade. We searched published English literature in last decade regarding etiology, diagnosis, treatment, and prevention of AVB using PubMed and Cochrane Database of Systematic Reviews. Respiratory syncytial virus is the most common causative agent. The diagnosis is mainly clinical with limited role of diagnostic investigations and chest radiographs are not routinely indicated. The management of AVB remains a challenge, as the role of various interventions is not clear. Supportive care in from of provision of heated and humidified oxygen and maintaining hydration are main interventions. The use of pulse oximetry helps to guide the administration of oxygen. Trials and systematic reviews evaluated various interventions like nebulized adrenaline, bronchodilators and hypertonic saline, corticosteroids, different modes of noninvasive ventilation (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and noninvasive positive pressure ventilation [NPPV]), surfactant, heliox, chest physiotherapy, and antiviral drugs. The interventions which showed some benefits in infants and children with AVB are adrenaline and hypertonic saline nebulization, HFNC, CPAP, NIV, and surfactant. The routine administration of antibiotics, bronchodilators, corticosteroids, steam inhalation, chest physiotherapy, heliox, and antiviral drugs are not recommended.

Role of nebulized epinephrine in moderate bronchiolitis: a quasi-randomized trial

BACKGROUND/AIMS

Bronchiolitis is the most common lower respiratory illness that characteristically affects the children below 2 years of age accounting about 2-3% of patients admitted to hospital each year [1-4]. We compared the effect of racemic epinephrine (RE) and 3% hypertonic saline (HS) nebulization on the length of stay (LOS) in the hospital.

METHODS

We looked at the infants with moderate bronchiolitis, from October 2013 to March 2014. Out of eighty cases, 16 in HS and 18 in RE groups were enrolled. At the time of admission, 0.2 ml of RE added to 1.8 ml of distilled water was nebulized to RE group, as compared with 2 ml of 3% HS in nebulized form. RE was re-administered if needed on 6 h in comparison with 3% HS at the frequency of 1 to 4 h.

RESULTS

One infant from RE group and three infants from HS group were excluded due to progression towards severe bronchiolitis. The LOS in RE group ranged between 18 and 160 h (mean 45 h), while in HS group, LOS was 18.50-206 h (mean 74.3 h). The LOS was significantly short in RE group (p value 0.015) which was statistically significant.

CONCLUSION

Racemic epinephrine nebulization as first-line medication may significantly reduce the length of hospital stay in infants with moderate bronchiolitis in comparison with nebulized HS.

Multi-dose Oral Ondansetron for Pediatric Gastroenteritis: study Protocol for the multi-DOSE oral ondansetron for pediatric Acute GastroEnteritis (DOSE-AGE) pragmatic randomized controlled trial

BACKGROUND

There are limited treatment options that clinicians can provide to children presenting to emergency departments with vomiting secondary to acute gastroenteritis. Based on evidence of effectiveness and safety, clinicians now routinely administer ondansetron in the emergency department to promote oral rehydration therapy success. However, clinicians are also increasingly providing multiple doses of ondansetron for home use, creating unquantified cost and health system resource use implications without any evidence to support this expanding practice.

METHODS/DESIGN

DOSE-AGE is a randomized, placebo-controlled, double-blinded, six-center, pragmatic clinical trial being conducted in six Canadian pediatric emergency departments (EDs). In September 2019 the study began recruiting children aged 6 months to 18 years with a minimum of three episodes of vomiting in the 24 h preceding enrollment, <72 h of gastroenteritis symptoms and who were administered a dose of ondansetron during their ED visit. We are recruiting 1030 children (1:1 allocation via an internet-based, third-party, randomization service) to receive a 48-h supply (i.e., six doses) of ondansetron oral solution or placebo, administered on an as-needed basis. All participants, caregivers and outcome assessors will be blinded to group assignment. Outcome data will be collected by surveys administered to caregivers 24, 48 and 168 h following enrollment. The primary outcome is the development of moderate-to-severe gastroenteritis in the 7 days following the ED visit as measured by a validated clinical score (the Modified Vesikari Scale). Secondary outcomes include duration and frequency of vomiting and diarrhea, proportions of children experiencing unscheduled health care visits and intravenous rehydration, caregiver satisfaction with treatment and safety. A preplanned economic evaluation will be conducted alongside the trial.

DISCUSSION

Definitive data are lacking to guide the clinical use of post-ED visit multidose ondansetron in children with acute gastroenteritis. Usage is increasing, despite the absence of supportive evidence. The incumbent additional costs associated with use, and potential side effects such as diarrhea and repeat visits, create an urgent need to evaluate the effect and safety of multiple doses of ondansetron in children focusing on post-emergency department visit and patient-centered outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03851835. Registered on 22 February 2019.

Innate Type 2 Responses to Respiratory Syncytial Virus Infection

Respiratory syncytial virus (RSV) is a common and contagious virus that results in acute respiratory tract infections in infants. In many cases, the symptoms of RSV remain mild, however, a subset of individuals develop severe RSV-associated bronchiolitis. As such, RSV is the chief cause of infant hospitalization within the United States. Typically, the immune response to RSV is a type 1 response that involves both the innate and adaptive immune systems. However, type 2 cytokines may also be produced as a result of infection of RSV and there is increasing evidence that children who develop severe RSV-associated bronchiolitis are at a greater risk of developing asthma later in life. This review summarizes the contribution of a newly described cell type, group 2 innate lymphoid cells (ILC2), and epithelial-derived alarmin proteins that activate ILC2, including IL-33, IL-25, thymic stromal lymphopoietin (TSLP), and high mobility group box 1 (HMGB1). ILC2 activation leads to the production of type 2 cytokines and the induction of a type 2 response during RSV infection. Intervening in this innate type 2 inflammatory pathway may have therapeutic implications for severe RSV-induced disease.

Evaluating the Placebo Status of Nebulized Normal Saline in Patients With Acute Viral Bronchiolitis: A Systematic Review and Meta-analysis

IMPORTANCE

In therapeutic trials for acute viral bronchiolitis, consistent clinical improvement in groups that received nebulized normal saline (NS) as placebo raises the question of whether nebulized NS acts as a treatment rather than a placebo.

OBJECTIVE

To measure the short-term association of nebulized NS with physiologic measures of respiratory status in children with bronchiolitis by analyzing the changes in these measures between the use of nebulized NS and the use of other placebos and the changes before and after nebulized NS treatment.

DATA SOURCES

MEDLINE and Scopus were searched through March 2019, as were bibliographies of included studies and relevant systematic reviews, for randomized clinical trials evaluating nebulized therapies in bronchiolitis.

STUDY SELECTION

Randomized clinical trials comparing children 2 years or younger with bronchiolitis who were treated with nebulized NS were included. Studies enrolling a treatment group receiving an alternative placebo were included for comparison of NS with other placebos.

DATA EXTRACTION AND SYNTHESIS

Data abstraction was performed per PRISMA guidelines. Fixed- and random-effects, variance-weighted meta-analytic models were used.

MAIN OUTCOMES AND MEASURES

Pooled estimates of the association with respiratory scores, respiratory rates, and oxygen saturation within 60 minutes of treatment were generated for nebulized NS vs another placebo and for change before and after receiving nebulized NS.

RESULTS

A total of 29 studies including 1583 patients were included. Standardized mean differences in respiratory scores for nebulized NS vs other placebo (3 studies) favored nebulized NS by -0.9 points (95% CI, -1.2 to -0.6 points) at 60 minutes after treatment (P < .001). There were no differences in respiratory rate or oxygen saturation comparing nebulized NS with other placebo. The standardized mean difference in respiratory score (25 studies) after nebulized NS was -0.7 (95% CI, -0.7 to -0.6; I2 = 62%). The weighted mean difference in respiratory scores using a consistent scale (13 studies) after nebulized NS was -1.6 points (95% CI, -1.9 to -1.3 points; I2 = 72%). The weighted mean difference in respiratory rate (17 studies) after nebulized NS was -5.5 breaths per minute (95% CI, -6.3 to -4.6 breaths per minute; I2 = 24%). The weighted mean difference in oxygen saturation (23 studies) after nebulized NS was -0.4% (95% CI, -0.6% to -0.2%; I2 = 79%).

CONCLUSIONS AND RELEVANCE

Nebulized NS may be an active treatment for acute viral bronchiolitis. Further evaluation should occur to establish whether it is a true placebo.

Bronchiolitis: an update on management and prophylaxis

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children less than 2 years of age in the UK. Respiratory syncytial virus is the most common virus associated with bronchiolitis and has the highest disease severity, mortality and cost. Bronchiolitis is generally a self-limiting condition, but can have serious consequences in infants who are very young, premature, or have underlying comorbidities. Management of bronchiolitis in the UK is guided by the National Institute for Health and Care Excellence (2015) guidance. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Pharmacological interventions including nebulized bronchodilators, steroids and antibiotics generally have limited or no evidence of efficacy and are not advised by National Institute of Health and Care Excellence. Antiviral therapeutics remain in development. As treatments are limited, there have been extensive efforts to develop vaccines, mainly targeting respiratory syncytial virus. At present, the only licensed product is a monoclonal antibody for passive immunisation. Its cost restricts its use to those at highest risk. Vaccines for active immunisation of pregnant women and young infants are also being developed.

Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis

OBJECTIVE

Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children.

DESIGN

Systematic review of primary studies.

DATA SOURCES

Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017.

ELIGIBILITY CRITERIA

Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days.

DATA EXTRACTION AND SYNTHESIS

One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose.

RESULTS

Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events.

CONCLUSIONS

Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.

Objective measurement of nocturnal cough in infants with acute bronchiolitis

OBJECTIVES

The objective measurement of the cough severity and the assessment of the pattern of nocturnal coughing could be useful in the treatment of respiratory diseases in children.

STUDY DESIGN

In children with respiratory syncytial virus (RSV)-induced acute bronchiolitis, coughs were recorded using our original system with a microphone and accelerometer, and analyzed using our customized software program. The number of coughs in every 30-minute interval was measured in patients with acute bronchiolitis (n = 20), and their results were compared with those of infants with asthma exacerbation (n = 16).

RESULTS

The cough count in children with acute bronchiolitis (median: 108.0/night) was almost as high as that in children with asthma exacerbation (median: 119/night). However, the time-dependent pattern of overnight cough was different in infants with acute bronchiolitis and those with asthma exacerbation. In the infants with asthma exacerbation, cough frequency significantly increased while falling asleep and waking up as compared to midnight (p < 0.001 and p < 0.001, respectively). However, these differences were not found in infants with acute bronchiolitis.

CONCLUSIONS

Our data demonstrated that the number of coughing events due to acute bronchiolitis was similar to that of acute asthma exacerbation, although the acute bronchiolitis did not show a characteristic overnight cough pattern.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

BACKGROUND

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments.

METHODS

We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge.

FINDINGS

Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50).

INTERPRETATION

Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis.

FUNDING

None.

Review shows substantial variations in the use of medication for infant bronchiolitis between and within countries

AIM

Meta-analyses of randomised controlled trials on infant bronchiolitis do not support medication. We summarised the current data and evaluated the real-life use of medication for infants treated for bronchiolitis in hospitals, including paediatric wards, emergency departments and paediatric intensive care units (PICU).

METHODS

We searched PubMed for studies published from 2009 to 2018 that provided data on the real-life use of adrenaline, salbutamol, corticosteroids or antibiotics for infants hospitalised for bronchiolitis.

RESULTS

The review identified 10 such studies and showed substantial variations in medication for infant bronchiolitis between different countries and even between different hospitals in the same country. A multi-centre study including 38 hospitals in eight countries reported that a mean of 29% infants admitted for bronchiolitis received drugs without any research-based evidence on their effectiveness, ranging from 9% in Australia and New Zealand to 58% in Spain and Portugal. In addition, an American prospective multi-centre study of 16 PICUs reported that bronchodilators were used by a mean of 60%, corticosteroids by 33% and antibiotics by 63%. Other studies reported that higher ages and a history of wheezing increased the use of medication.

CONCLUSION

There were substantial variations in bronchiolitis treatment between, and within, different countries.

Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children

INTRODUCTION

Rest until symptom-free, followed by a progressive stepwise return to activities, is often prescribed in the management of paediatric concussions. Recent evidence suggests prolonged rest may hinder recovery, and early resumption of physical activity may be associated with more rapid recovery postconcussion. The primary objective is to determine whether the early reintroduction of non-contact physical activity beginning 72 hours postinjury reduces postconcussive symptoms at 2 weeks in children following an acute concussion as compared with a rest until asymptomatic protocol.

METHODS AND ANALYSIS

This study is a randomised clinical trial across three Canadian academic paediatric emergency departments. A total of 350 participants, aged 10-17.99 years, who present within 48 hours of an acute concussion, will be recruited and randomly assigned to either the study intervention protocol (resumption of physical activity 72 hours postconcussion even if experiencing symptoms) or physical rest until fully asymptomatic. Participants will document their daily physical and cognitive activities. Follow-up questionnaires will be completed at 1, 2 and 4 weeks postinjury. Compliance with the intervention will be measured using an accelerometer (24 hours/day for 14 days). Symptoms will be measured using the validated Health and Behaviour Inventory. A linear multivariable model, adjusting for site and prognostically important covariates, will be tested to determine differences between groups. The proposed protocol adheres to the RCT-CONSORT guidelines.

DISCUSSION

This trial will determine if early resumption of non-contact physical activity following concussion reduces the burden of concussion and will provide healthcare professionals with the evidence by which to recommend the best timing of reintroducing physical activities.

TRIAL REGISTRATION NUMBER

Trial identifier (Clinicaltrials.gov) NCT02893969.

Periostin levels in children without respiratory disease

BACKGROUND

Periostin is a protein that serves as a downstream marker of the T-helper type 2 (Th2) cell response. It may serve to identify drug-responsive inflammatory phenotypes, particularly in children with asthma and possibly bronchiolitis. There are no published levels of periostin in healthy children <2 years of age, limiting interpretation of periostin levels in disease. We sought to explore the range of periostin levels of children <2 years without significant confounding illnesses.

METHODS

Children undergoing clinically indicated phlebotomy or having a peripheral intravenous catheter inserted prior to general anesthesia or procedural sedation were enrolled. A 0.5 mL sample of blood was collected and frozen at -70°C. After thawing, periostin was measured with a Luminex assay (R&D Systems, Minneapolis, MN). Medical record review and/or parental interview elicited potential variables associated with periostin. Association was evaluated using Mann-Whitney rank sum test, Kruskal-Wallis ANOVA, and Spearman correlation as appropriate.

RESULTS

Among 43 children (23 male, 20 female, age range 9-15.7 months), periostin levels were inversely correlated to age (r = -0.438, P = 0.003). Periostin levels also differed significantly between children <12mo (734.0 [576.6-906.5] ng/mL), 12-18mo (645.1 [363.8-538.2] ng/mL) and >18mo (416.4 [363.8-538.15] ng/mL) (P < 0.001).

CONCLUSION

In our sample of relatively healthy patients <2 years old, periostin levels were inversely correlated with age and not dependent on other studied variables. However, further work is needed to establish normal periostin values in young children.

Use of Social Psychology to Improve Adherence to National Bronchiolitis Guidelines

OBJECTIVES

The American Academy of Pediatrics' bronchiolitis guidelines recommend against albuterol and corticosteroids for treating and chest radiographs (CRs) for diagnosing infants with bronchiolitis. However, high rates of nonadherence have been documented. Our objective was to improve guideline adherence in infants with bronchiolitis.

METHODS

This quality improvement study was conducted in 1 urban academic pediatric primary care clinic caring for predominately minority and publicly insured children. We tested provider guideline education, display of guidelines in patient care areas, and monthly e-mails to all providers documenting deviation rates, with individual e-mails to providers who deviated. P-charts and interrupted time series analysis were used to estimate the effect of the intervention.

RESULTS

There were 380 children <2 years of age with a diagnosis of bronchiolitis in the 16 nonsummer months preintervention and 417 in the 15 postintervention months. Rates of prescribed and administered albuterol declined from 45.7% in the baseline period to 13.7% in the intervention period and CR use dropped from a mean of 10.1% to 3.4%, both demonstrating special cause variation. Steroid use did not change significantly. In interrupted time series analyses, the intervention was associated with a significant decrease in albuterol use (P < .001) but not in CR or steroid use. Emergency department visits declined slightly but admissions for bronchiolitis were stable.

CONCLUSIONS

Traditional quality improvement efforts coupled with social psychology techniques resulted in improved guideline adherence in outpatient bronchiolitis management. Additional study will help identify which techniques are most effective for increasing guideline adherence in cases of low-value care.

Australasian bronchiolitis guideline

AIM

Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population.

METHODS

The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies.

RESULTS

The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting.

CONCLUSION

This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.

Which ICD-9-CM codes should be used for bronchiolitis research?

Background

Bronchiolitis is a common respiratory disorder in children. Although there are specific ICD-9-CM diagnosis codes for bronchiolitis, the illness is often coded using broader diagnosis codes. This creates the potential for subject misclassification if researchers rely on specific diagnosis codes when assembling retrospective cohorts. Here we challenge the common research practice of relying on specific diagnosis codes for bronchiolitis.

Methods

We examined the use of diagnosis codes for the first episode of bronchiolitis, bronchitis, acute asthma, and bronchospasm and wheezing, in children younger than six and 24 months in the State of California Medic-Aid database. We categorized codes as narrow or broad diagnosis codes. We compared patient, geographic, and temporal characteristics of the different diagnoses codes.

Results

We identified visits from 48,732 children for first episode of wheezing illness. We retained 48,269 who had the diagnosis codes and data of interest. Diagnosis codes for acute asthma were widely used, even in children younger than six months in whom a diagnosis code for bronchiolitis would have been anticipated. The temporal pattern was similar across all diagnoses. Antipyretics were prescribed more often in those with diagnosis codes for bronchiolitis and bronchitis. Other statistically significant differences were too small to usefully distinguish the groups. There was substantial geographic variability in the diagnosis codes selected.

Conclusion

Users of Medic-Aid administrative data should generally favor broad rather than narrow definitions of bronchiolitis and should perform sensitivity analysis comparing broad and narrow definitions.

Electronic supplementary material

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